Evaluation of the factors related to postmastectomy breast reconstruction

A retrospective study was conducted in 75 consecutive patients requiring po stmastectomy breast reconstruction over a period of 30 months. Each woman w as offered one of the following four reconstructive options: free transvers e rectus abdominis musculocutaneous flap (total number of reconstructions, n = 34); latissimus dorsi musculocutaneous flap (with or without expander a nd implant, n = 14); endoscopically assisted harvest of the latissimus dors i muscle (with expander and implant, n = 13): and application of expander a nd implant only (n = 12). Of those patients originally selected for retrospective study, six did not meet the short-term prognostic criteria, and concerted attempts to contact two others proved unsuccessful. The remaining 67 patients were examined for the clinically assessed aesthetic appearance of the reconstructed breast(s ), the subjective self-assessment of patient satisfaction, and the possible development of postoperative complications. Of these patients, six require d bilateral surgery, which accounts for a final sample size of 73 individua l breast reconstructions. The 67 individual patients were assessed after a minimum time of 6 months post-reconstruction and became the sampling units for analysis. The free transverse rectus abdominis musculocutaneous flap procedure was th e preferred method of breast reconstruction in 34 of 73 patients (47 percen t), provided that it was generally agreed that the patient could endure a p rolonged operation and that there was sufficient unscarred abdominal tissue available. Thereafter, postmastectomy radiotherapy at the chest wall becam e the primary criterion for assignment of a patient to a particular surgica l procedure. Whenever radiotherapy resulted in poor-quality skin at the che st wall, endoscopically assisted transfer of latissimus dorsi muscle flap w as considered to be the optimal treatment (13 of 73 patients, or 18 percent ). Body mass index and smoking were secondary factors that were taken into account when this alternative technique was being considered. In the absence of radiotherapy, and provided that the chest wall was minima lly scarred, patients who were reluctant to have reconstruction with autolo gous tissue were treated with expander and implant only (12 of 73, or 16 pe rcent). This third procedure is a physically less arduous ordeal for the pa tient and was therefore the choice for all patients for whom a prolonged op eration was not a realistic option. The fourth (and final) surgical procedu re, latissimus dorsi musculocutaneous flap (with or without expander and im plant), was selected for all patients with a better quality of skin over th e chest wall, those whose abdomen was extensively scarred, and those who we re on a general surgeon's operating list to undergo immediate breast recons truction after mastectomy (14 of 73, or 19 percent). Equally good aesthetic results could be demonstrated with each of the four treatment options, provided that the reconstructive procedure selected was optimal for the individual patient and in accordance with the criteria desc ribed above. A variety of potential risk factors were considered for associ ation with postoperative complications, including prescribed medication, ob esity, smoking behavior, use of radiotherapy, and the recorded aggregated o perative time. Of these, only body mass index (p < 0.001) and use of steroi ds (p = 0.016) were identified as having statistically significant effects on the incidence of adverse events. Finally, the general level of satisfaction expressed by the patient was hig hly correlated with a good appearance of the reconstructed breast, the phys ical comfort experienced while wearing a brassiere, and the general mobilit y of the unsupported reconstruction.